Integrated and Device-Based Endotracheal Tube Stabilisation During General Anaesthesia: A Systematic Review and Meta-analysis

Abstract

Background. Adhesive tape is still the usual way of holding an orotracheal tube in place during general anaesthesia.
Tube migration, accidental extubation, endobronchial intubation and pressure injury to the face and lips nevertheless
remain familiar hazards, and they are most likely when the patient is prone or lateral or when the head is shared with
the surgical team. Commercial tube holders have been available for some years, and integrated devices that combine
securement with a bite block, an eye shield or a suction port have appeared more recently. The reviews published so
far deal with the intensive care unit; no one has yet synthesised the intraoperative question.
Methods. We followed PRISMA 2020. PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus, Web of
Science and CINAHL were searched from inception with no language limit, together with trial registries and the
reference lists of included papers. We accepted randomised and non-randomised comparative studies of patients
receiving general anaesthesia through an orotracheal tube, provided a device-based or integrated system was
compared with adhesive tape or with another device. Clinically relevant intraoperative displacement was the primary
outcome. We appraised randomised trials with RoB 2 and the non-randomised study with ROBINS-I, and pooled
dichotomous data as odds ratios and risk ratios using DerSimonian-Laird random-effects models with the Hartung-
Knapp-Sidik-Jonkman adjustment. Certainty was graded with GRADE.
Results. Six comparative operating-theatre studies were eligible. Only two, together
enrolling 104 patients, reported dichotomous displacement counts that could be
combined, and both favoured the device. The random-effects odds ratio was 0.05 (95%
CI 0.001 to 1.49; p = 0.083) with substantial heterogeneity (I² = 79.4%), and the risk
ratio was 0.14 (95% CI 0.01 to 2.57). Fixed-effect estimates reached significance (OR
0.12, 95% CI 0.04 to 0.39; RR 0.39, 95% CI 0.20 to 0.76), the difference reflecting a two-
study model that contains a zero cell. A single trial measuring displacement
continuously reported a mean difference of −3.00 mm (95% CI −5.98 to −0.02).
Accidental extubation and endobronchial intubation were rare and reported
inconsistently. In absolute terms 708 per 1000 with tape corresponds to 102 per 1000
with a device (95% CI 4 to 783), and the larger contributing trial had a post hoc
fragility index of 1. Certainty was very low for every outcome.
Conclusions. Every study that measured tube movement found less of it with a device than with tape, but the
operating-theatre evidence is thin, inconsistently defined and at moderate to high risk of bias, and the pooled estimate
is correspondingly imprecise. Trials of adequate size, using an agreed definition of displacement and a blinded
assessor, are needed before mechanical securement can be recommended for routine use.
Registration. PROSPERO [number to be inserted].